scholarly journals P022 Audit of musculoskeletal ultrasound to optimise DMARD therapy among patients in a district general hospital

Rheumatology ◽  
2021 ◽  
Vol 60 (Supplement_1) ◽  
Author(s):  
Michael Chen-Xu ◽  
Dovenik Hyseni ◽  
Katerina Achilleos
Keyword(s):  
Chronic Pain ◽  
Inflammatory Arthritis ◽  
Significant Proportion ◽  
Musculoskeletal Ultrasound ◽  
Tender Joint Count ◽  
Tender Joint ◽  
Biologic Dmards ◽  
Retrospective Audit ◽  
The Impact ◽  
Active Synovitis

Abstract Background/Aims  Musculoskeletal ultrasound (MSUS) has utility in optimising the use of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologic DMARDs (bDMARDs) in patients with inflammatory arthritis. However, it is unclear whether this is useful among patients with concomitant chronic pain and/or fibromyalgia, who often have elevated disease activity scores. We aimed to evaluate the impact of MSUS on inflammatory arthritis patients with concomitant chronic pain and/or fibromyalgia who met criteria for treatment escalation in a district general rheumatology service. Methods  We conducted a retrospective audit of inflammatory arthritis patients with concomitant chronic pain and/or fibromyalgia who were eligible for DMARD escalation and underwent a MSUS since 2017. Scanning was performed by either a trained rheumatologist or musculoskeletal ultrasonographer. Synovitis was assessed following OMERACT guidelines. Results  43 patients with inflammatory arthritis and concomitant chronic pain and/or fibromyalgia who underwent MSUS were identified. The mean age was 57.0 years (SD 15.6), and 34 patients (79%) were female. Rheumatoid arthritis was the most frequent diagnosis with 32 patients (74%), with psoriatic arthritis in 5 (12%), undifferentiated inflammatory arthritis in 4 (9%) and axial spondylarthritis (axSpA) in 2 (5%). 20 patients (47%) had a concurrent diagnosis of fibromyalgia. The median tender joint count among non-axSpA patients was 10 (IQR 4-15) and 2 (IQR 0-4) for swollen joints. MSUS was requested for consideration of a bDMARD switch in 21 patients (49%), a new bDMARD in 15 (35%), and starting an adjunctive csDMARD among 7 (16%). 34 patients (79%) were already established on csDMARDs, with 15 patients (35%) being on one or more, and methotrexate being the most prescribed csDMARD in 26 (76%). 14 patients (33%) were already established on bDMARDs, 9 (21%) had been on them previously and 20 (47%) were bDMARD naïve. Among those on bDMARDs, anti-TNFs agents were the most prescribed (71%). Active synovitis was identified in 17 patients (40%). Greyscale synovitis, tenosynovitis and enthesitis were seen in 30 (70%), 10 (23%) and 2 patients (5%), respectively. Erosions were identified in 12 patients (28%), with 2 (17%) having new erosions. 27 patients (63%) had either a csDMARD started (n = 7, 33%), or a bDMARD started (n = 11, 31%) or switched (n = 9, 25%) after MSUS. Those with fibromyalgia were less likely to start or switch DMARDs (8/20 patients, 40%) than those without (19/23 patients, 82.6%), Pchi-squared = 0.004. Furthermore, active synovitis on MSUS was associated with DMARD escalation (14/17 patients [82.4%] with synovitis versus 13/26 patients [50%] without; Pchi-squared = 0.03). Conclusion  MSUS avoided unnecessary DMARD escalation in a significant proportion of patients with inflammatory arthritis and features of concomitant chronic pain and/or fibromyalgia (n = 26, 37%), potentially resulting in reduced patient exposure to harmful DMARD side effects, and cost savings for the service. Disclosure  M. Chen-Xu: None. D. Hyseni: None. K. Achilleos: None.

Evaluation of Serum Calprotectin Level and Disease Activity in Patients with Rheumatoid Arthritis

2019 ◽  
Vol 15 (4) ◽  
pp. 316-320
Author(s):  
Mir Amir Aghdashi ◽  
Seyedmostafa Seyedmardani ◽  
Sholeh Ghasemi ◽  
Zohre Khodamoradi
Keyword(s):  
Rheumatoid Arthritis ◽  
Disease Activity ◽  
Inflammatory Arthritis ◽  
Unknown Etiology ◽  
Tender Joint Count ◽  
Serum Samples ◽  
Tender Joint ◽  
Cross Sectional ◽  
Calprotectin Level ◽  
Remission Phase

Background: Rheumatoid Arthritis (RA) is the most common type of chronic inflammatory arthritis with unknown etiology marked by a symmetric, peripheral polyarthritis. Calprotectin also can be used as a biomarker of disease activity in inflammatory arthritis and other autoimmune diseases. Objective: In this study, we evaluated the association between serum calprotectin level and severity of RA activity. Methods: A cross-sectional study was conducted on 44 RA patients with disease flare-up. Serum samples were obtained from all patients to measure calprotectin, ESR, CRP prior to starting the treatment and after treatment period in the remission phase. Based on Disease Activity Score 28 (DAS28), disease activity was calculated. Results: Of 44 RA patients, 9(20.5%) were male and 35(79.5%) were female. The mean age of our cases was 53±1.6 years. Seventeen (38.6%) patients had moderate DAS28 and 27(61.4%) had high DAS28. The average level of calprotectin in the flare-up phase was 347.12±203.60 ng/ml and 188.04±23.58 ng/ml in the remission phase. We did not find any significant association between calprotectin and tender joint count (TJC; P=0.22), swollen joint count (SJC; P=0.87), and general health (GH; P=0.59), whereas significant associations were found between the calprotectin level and ESR (p=0.001) and DAS28 (p=0.02). The average calprotectin level in moderate DAS28 (275.21±217.96 ng/ml) was significantly lower than that in high DAS28 (392.4±183.88 ng/ml) (p=0.05). Conclusion: We showed that the serum level of calprotectin can be a useful and reliable biomarker in RA activity and its severity. It also can predict treatment response.

scholarly journals EP31 Musculoskeletal ultrasound of rheumatoid arthritis pregnancy: a single centre experience

Rheumatology ◽  
2020 ◽  
Vol 59 (Supplement_2) ◽  
Author(s):  
Charles Raine ◽  
Jessica Manson ◽  
Coziana Ciurtin ◽  
Ian Giles
Keyword(s):  
Rheumatoid Arthritis ◽  
Disease Activity ◽  
Single Case ◽  
Post Partum ◽  
Power Doppler ◽  
Musculoskeletal Ultrasound ◽  
Tender Joint Count ◽  
Tender Joint ◽  
Low Disease Activity ◽  
In Pregnancy

Abstract Background The utility of musculoskeletal ultrasound (MSK-US) in the measurement of disease activity of rheumatoid arthritis (RA) is well established. However, it has not been formally studied in pregnancy, with the literature limited to a single case report. Standard disease activity assessment in RA pregnancy comprises measurement of the DAS28(3) CRP score, which removes the visual analogue score (VAS) and replaces ESR with CRP, as both of these components may be confounded by pregnancy. Use of this modified score remains problematic as the tender joint count may be affected by non-specific musculoskeletal pain in pregnancy, and the swollen joint count may be obscured by peripheral oedema, especially late in pregnancy. No study of RA in pregnancy has used MSK-US to measure disease activity. Our objective was to conduct a pilot study of MSK-US in RA pregnancy, and compare findings with clinical assessment using the DAS28(3)CRP score. Methods We offered MSK-US to pregnant RA patients attending the UCLH obstetric rheumatology clinic from September 2018 to September 2019. Patients were assessed longitudinally through pregnancy/post-partum where possible. Examination was undertaken using a Logiq S8 US machine. The standard protocol comprised 22-joint assessment of hands (dorsal longitudinal and transverse views of wrists, metacarpophalangeal and proximal interphalangeal joints). In the feet, bilateral MTP joints were scanned with longitudinal views. Quantification of Power Doppler (PD) signal and grey scale (GS) synovitis was made as per the Outcome Measures in Rheumatoid Arthritis Clinical Trials (OMERACT) US definitions. PD and GS scores were calculated as mean scores of all joints scanned. Results To date, 17 pregnant RA patients have undergone a total of 35 MSK-US studies. Disease activity assessments showed 10/17 patients with persistent low activity through pregnancy, 5/17 with moderate or good response, 1/17 with no response and 1/17 with a moderate flare. Overall, PD scores correlated well with DAS28(3) CRP assessment (R2 = 0.68). All patients at moderate or high disease activity by DAS28(3) CRP had ≥1 joint with detectable PD signal, but 2/21 patients clinically in ‘remission’ and 3/7 patients in ‘low disease activity’ had detectable PD. One patient with only 2 tender and 1 swollen joints (and normal CRP; DAS28 3.17) had very extensive PD signal and contributed to the decision to recommence anti-TNF treatment in the 3rd trimester. It was noted that increased vascularity in pregnancy can complicate the assessment of synovial PD signal. MSK-US was particularly helpful in distinguishing true joint synovitis from subcutaneous oedema in the feet. Conclusion This is the first series of MSK-US in pregnant RA patients. The detection of active joint synovitis (by PD signal) in clinical remission/low disease activity states suggests a potential role for MSK-US in confirming apparent low disease activity in pregnancy, and thus guiding stratification of treatment. Disclosures C. Raine None. J. Manson None. C. Ciurtin None. I. Giles None.

scholarly journals The impact of smoking on the activity of rheumatoid arthritis

2015 ◽  
Vol 21 (4) ◽  
pp. 201-205
Author(s):  
Dusa Daniela ◽  
Hanzu-Pazara Loredana ◽  
Pana Camelia ◽  
Tudorache Monica ◽  
Suta Maria
Keyword(s):  
Rheumatoid Arthritis ◽  
Disease Activity ◽  
Smoking Status ◽  
Demographic Variables ◽  
Tender Joint Count ◽  
Medical Clinic ◽  
Tender Joint ◽  
A Prospective Study ◽  
The Impact ◽  
Clinical Emergency

Abstract Smoking is the environmental factor involved in rheumatoid arthritis etiopathology. The data from the literature show that the smoking influence both the appearance and the development of rheumatoid arthritis. The study aims to analyzes how smoking affects disease activity. A prospective study was conducted on a sample of 264 rheumatoid arthritis patients who were registered with the Department of Rheumatology at the Medical Clinic II, Clinical Emergency Hospital “St. Andrew “, Constanta. We performed demographic variables, clinical and biological. We specifically inquiring smoking status and parameters of disease activity variables expressed by DAS28 and its variables. Smoking status was correlated with high and moderate active disease and ESR values and pacient global assessment. No statistically significantly correlated with CRP, tender joint count, swollen joint count. In conclusion, smoking influences disease activity.

scholarly journals Relationship Between Fatigue and Inflammation, Disease Duration, and Chronic Pain in Psoriatic Arthritis: An Observational DANBIO Registry Study

2019 ◽  
Vol 47 (4) ◽  
pp. 548-552 ◽  
Author(s):  
Marie Skougaard ◽  
Tanja Schjødt Jørgensen ◽  
Signe Rifbjerg-Madsen ◽  
Laura C. Coates ◽  
Alexander Egeberg ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Psoriatic Arthritis ◽  
Disease Duration ◽  
Joint Damage ◽  
Principal Component ◽  
Inflammatory Factors ◽  
Tender Joint Count ◽  
Cross Sectional Survey ◽  
Tender Joint ◽  
Cross Sectional

Objective.Fatigue is one of the most significant symptoms, and an outcome of great importance, in patients with psoriatic arthritis (PsA), but associations between underlying components of fatigue experienced by patients in relation to the disease have been sparsely investigated. The objectives were to describe the degree of fatigue in patients with PsA, and to examine important components associated with fatigue.Methods.We performed a cross-sectional survey including patients registered in the Danish nationwide registry DANBIO from December 2013 to June 2014. Principal component analysis (PCA) was used to identify factors associated with fatigue.Results.A total of 1062 patients with PsA were included in the study. A PCA reduced co-variables into 3 components explaining 63% of fatigue in patients. The first component, contributing to 31% of fatigue, was composed of inflammatory factors including swollen and tender joints, physician’s global assessment, elevated C-reactive protein (CRP), and high Pain Detect Questionnaire (PDQ) score. The second component, contributing to 17% of fatigue, consisted of increasing age and long disease duration. The third component, contributing to 15% of fatigue, consisted of high PDQ score, tender joint count, increasing age, and concomitant low CRP, suggestive of a chronic pain component consisting of central pain sensitization or structural joint damage.Conclusion.Fatigue in patients with PsA may be driven by clinical inflammatory factors, disease duration, and chronic pain in the absence of inflammation.

scholarly journals Dactylitis is an indicator of a more severe phenotype independently associated with greater SJC, CRP, ultrasound synovitis and erosive damage in DMARD-naive early psoriatic arthritis

2021 ◽  
pp. annrheumdis-2021-220964
Author(s):  
Sayam Dubash ◽  
Oras A Alabas ◽  
Xabier Michelena ◽  
Leticia Garcia-Montoya ◽  
Richard J Wakefield ◽  
...  
Keyword(s):  
Psoriatic Arthritis ◽  
Disease Burden ◽  
Severe Disease ◽  
Power Doppler ◽  
Tender Joint Count ◽  
Tender Joint ◽  
Bone Erosions ◽  
Reactive Protein ◽  
The Impact ◽  
Early Psoriatic Arthritis

ObjectiveTo characterise the impact of dactylitis in disease-modifying antirheumatic drug (DMARD)-naive early psoriatic arthritis (PsA).MethodsPatients with early PsA meeting the classification criteria for PsA (CASPAR) were recruited. Clinical outcomes were recorded, and ultrasonography was conducted to assess grey scale (GS) and power Doppler (PD) synovitis, periarticular cortical bone erosions and enthesitis. The cohort was dichotomised by the presence or absence of dactylitis.ResultsOf 177 patients with PsA, those with dactylitis (dactylitic PsA (81/177, 46%)) had higher tender joint count (p<0.01), swollen joint count (SJC) (p<0.001) and C reactive protein (CRP) (p<0.01) than non-dactylitic PsA. Dactylitis was more prevalent in toes (146/214 (68.2%)) than fingers (68/214 (31.8%)); ‘hot’ dactylitis was more prevalent than ‘cold’ (83.6% vs 16.4%). Ultrasound (US) synovitis and erosions were significantly more prevalent in dactylitic PsA (p<0.001 and p<0.001, respectively). Exclusion of dactylitis in dactylitic PsA confirmed significantly greater SJC (3 vs 1, p=0.002), US synovitis (GS ≥2: 20.6% vs 16.1%, p<0.001, or PD ≥1: 5.1% vs 3.3%, p<0.001) and erosions (1.1% vs 0.5% joints, p=0.008; 26.1% vs 12.8% patients, p=0.035%) than non-dactylitic PsA. Synovitis (GS ≥2 and/or PD ≥1) occurred in 53.7% of dactylitis. No substantial differences were observed for US enthesitis.ConclusionDactylitis signifies a more severe disease phenotype independently associated with an increased disease burden with greater SJC, CRP, US-detected synovitis and bone erosions in DMARD-naive early PsA and may be a useful discriminator for early risk stratification.

scholarly journals P81 The impact of musculoskeletal ultrasound on the referral of patients with suspected inflammatory arthritis from primary care

Rheumatology ◽  
2020 ◽  
Vol 59 (Supplement_2) ◽  
Author(s):  
Kenneth F Baker ◽  
Eliana Fatone ◽  
Jennifer Hamilton
Keyword(s):  
Primary Care ◽  
Secondary Care ◽  
Inflammatory Arthritis ◽  
Clinical History ◽  
Musculoskeletal Ultrasound ◽  
Radiology Department ◽  
Queen Elizabeth Hospital ◽  
National Guidelines ◽  
Number Of Patients ◽  
The Impact

Abstract Background Musculoskeletal ultrasound (MSUS) is a helpful adjunct to clinical history and examination in the assessment of patients with suspected early inflammatory arthritis (EIA). Whereas MSUS is used widely by rheumatologists, data regarding the extent to which general practitioners (GPs) utilise MSUS in the assessment of patients with suspected EIA remain lacking. In this service evaluation, we aimed to quantify the MSUS workload originating from primary care, and its impact on the referral pathway of patients with suspected EIA. Methods We studied all patients ≥16 years of age who had an MSUS of the hands and wrists performed by the radiology department at the Queen Elizabeth Hospital (Gateshead, UK) between 1st January and 31st December 2018, and where the scan request originated from a GP within primary care. Electronic records were retrospectively reviewed to ascertain the scan request clinical details, radiology report, and subsequent referral of the patient for rheumatology review. The study was registered with the Trust Clinical Improvement Office. Results 189 patients were scanned: 137 (72%) female, median (IQR, range) age 56 (43-65, 16-91) years. Ultrasonographic abnormalities (synovial hypertrophy, synovitis and/or tenosynovitis) were observed in 31/87 (36%) of suspected EIA patients, and 22/102 (22%) patients without suspicion of EIA, with subsequent referral to rheumatology in 24 and 4 cases from each group respectively. Of the 24 patients with suspected EIA who were referred for rheumatological assessment, 7 were subsequently diagnosed with EIA (one seropositive rheumatoid arthritis [RA], three seronegative RA, two unspecified IA, one reactive arthritis) with a median (range) time from MSUS request to rheumatology referral of 36 (-5 - 58) days. None of the 4 patients referred from the non-EIA group were diagnosed with an inflammatory arthritis. Conclusion MSUS is widely used by GPs within our region for the assessment of suspected EIA, despite local and national guidelines supporting referral without imaging within 3 days of presentation. Furthermore, we show evidence that GPs interpret scan reports within the individual patient clinical context, with rheumatology referral less likely where the clinical suspicion of EIA is low. Normal MSUS findings contributed to avoidance of referral in 56/87 (64%) of suspected EIA cases, substantially reducing EIA referrals to secondary care. However, MSUS requests within primary care also contributed towards a delay in referral for a small number of patients with confirmed EIA, which we plan to address by signposting to local EIA referral guidelines within the radiology request system. A prospective study of MSUS in the triaging of EIA referrals to secondary care, combined with a qualitative study of the impact of MSUS on GP decision making, are warranted to better understand the potential impact of MSUS in the primary care setting for improved patient care and resource allocation. Disclosures K.F. Baker None. E. Fatone None. J. Hamilton None.

scholarly journals POS1258 MISSING THE WINDOW OF OPPORTUNITY: EARLY ARTHRITIS CLINICS IN TIMES OF COVID-19

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 913.1-913
Author(s):  
B. D’onofrio ◽  
L. De Stefano ◽  
B. L. Palermo ◽  
B. Xoxi ◽  
A. Manzo ◽  
...  
Keyword(s):  
At Risk ◽  
Diagnostic Delay ◽  
Early Arthritis ◽  
Classification Criteria ◽  
Tender Joint Count ◽  
Window Of Opportunity ◽  
Tender Joint ◽  
Acute Phase Reactants ◽  
The Impact ◽  
New Onset

Background:The outcomes of patients with chronic inflammatory arthritis (IA), such as rheumatoid arthritis (RA), have dramatically improved over the past 20 years. Earlier identification of IA and prompter treatment institution have been key advancements, promoted by the constitution of Early Arthritis Clinics (EAC) and the development of more sensitive classification criteria for RA. The outbreak of new COronaVIrus Disease 2019 (COVID-19) has quickly become a global health emergency and has forced a rearrangement in the management of other non-COVID-19 diseases. The impact of the lock-down of the healthcare systems on chronic inflammatory diseases such as RA is expected to be significant but is at present unknown.Objectives:To assess the effects of the lock-down imposed by the COVID-19 pandemic on the referral and clinical presentation of patients with new-onset RA.Methods:Data were retrieved from the Pavia EAC inception cohort, established in 2005 for the early identification of patients with new-onset IA. Referral criteria to the EAC include: ≥3 swollen joints (SJ) and/or <3 SJ and positive squeeze test and/or <3 SJ and morning stiffness >30 min. Demographic and clinical characteristics of the patients are assessed at baseline and regularly over follow-up.At 31 Dec 2020, the Pavia EAC collects information on 2.508 patients. For this study, baseline characteristics of the patients referred in the semester following the COVID-19 lock-down (Jul-Dec 2020) were compared with: (i) patients referred in the semester immediately preceding the lock-down (Jul-Dec 2019); (ii) patients referred in the semester following the publication of the 2010 RA classification criteria (Jan-Jun 2011); (iii) patients referred in the semester preceding the publication of the 2010 criteria (Jul-Dec 2009).Results:In the semester following the lock-down imposed by the COVID-19 pandemic, there was a decrease in the referral of patients with new-onset suspected IA compared with previous periods (n=71 vs n=91 in the semester before the lock-down, n=96 in the first semester of 2011, n=101 in the second semester of 2009). Furthermore, fewer of the referred patients fulfilled RA criteria at presentation (36.6% vs 44.3%, 46.5% and 42.9% in the other semesters). Among patients with RA, more were autoantibody-positive (72% vs 50%, 49.1% and 52.2%). There was a trend for increased diagnostic delay in the overall cohort of RA after the COVID-19 lock-down (Figure 1A). The delay was particularly longer in autoantibody-positive patients, returning to the values seen before the introduction of the 2010 RA criteria (Figure 1B). In contrast, the few autoantibody-negative patients were referred earlier (Figure 1C). Disease activity at presentation was significantly higher in RA patients presenting after the lock-down compared with the progressive trend for reduction observed over the previous years, irrespective of the autoantibody status (Figure 1D-F). Such increase was determined by an inversion of the trend towards lower levels of objective parameters of inflammation, such as the swollen joint count (Figure 1G-I) and acute phase reactants, and a further increase in the secular trend towards worsening of patient-derived measures, such as the tender joint count and patient global assessment (Figure 1J-L).Figure 1.Effects of COVID-19 lock-down on new-onset RA at presentation.Conclusion:The COVID-19 pandemic is posing unprecedented challenges in the management of patients suffering from chronic diseases. RA has returned to be diagnosed outside the window of opportunity, with a significantly higher inflammatory burden at presentation. The many benefits of early diagnosis, which have dramatically changed the outcomes of autoantibody-positive RA, are at risk of vanishing in short times. Equally important, autoantibody-negative RA is at risk of further under-diagnosis and under-treatment.Disclosure of Interests:Bernardo D’Onofrio: None declared, Ludovico De Stefano: None declared, Bianca Lucia Palermo: None declared, Blerina Xoxi: None declared, Antonio Manzo: None declared, Carlomaurizio Montecucco Speakers bureau: BMS, Lilly, Sanofi, Pfizer, Galapagos, Roche, Novartis, Serena Bugatti Speakers bureau: BMS, Lilly, Sanofi, Pfizer, Galapagos

Implication of Medical Treatment for Surgical Strategies in IBD

2019 ◽  
Vol 20 (13) ◽  
pp. 1363-1368
Author(s):  
Krisztina B. Gecse ◽  
Christianne J. Buskens
Keyword(s):  
Nutritional Status ◽  
Medical Treatment ◽  
Significant Proportion ◽  
Timing Of Surgery ◽  
Multidisciplinary Management ◽  
Key Factors ◽  
Surgical Strategies ◽  
Immunosuppressive Medications ◽  
Medical Paradigm ◽  
The Impact

Despite changing medical paradigm, still a significant proportion of patients with IBD require surgery. The patient&#039;s general condition, including nutritional status and the use of immunosuppressive medications is of great importance with regard to surgical complications, as well as the choice of optimal surgical strategy. The indication and the timing of surgery are key factors for the multidisciplinary management of IBD patients. The purpose of this review is to provide an overview on the impact of medical treatment on surgical strategies in IBD.

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